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175 Jonathan Dropkin Hofstra Northwell School of Medicine Robin Mary Gillespie City University of New York School of Labor and Urban Studies Lewis Pepper Queens College Contents 176 Introduction 177 Health Factors Associated with Restroom Access for Transit Vehicle Operators 177 Risk Factors, Explained 177 Water as Mediator 178 Areas of Potential Health Impact of Restricted Restroom Access 178 Mood and Cognition 179 Cardiovascular SystemâHypertension, Cardiovascular Disease, Stroke 180 Gastrointestinal System 180 Constipation 180 Colorectal Cancer 181 Urinary Tract 181 Bladder Problems 181 Urinary Tract Infections 182 Kidney Stones 182 Bladder Cancer 183 Reproductive System 183 Prostate Health 184 Pregnancy and Birth Outcomes 184 Male Infertility 185 Multiple Organ Systems: Toxic Shock Syndrome 185 Public Health Impact as Described in the Press 186 Health Issues and Changes That May Affect Restroom Access and Related Risk 187 Health Literature Summary 188 References A P P E N D I X B Summary of Health Literature
176 Improving the Safety, Health, and Productivity of Transit Operators Through Adequate Restroom Access Introduction Transit vehicle operators have long felt that limited restroom access has a negative impact on their well-established health problems and on workplace safety. There is extensive evidence that transit employees generally, and bus operators in particular, have higher rates of diabetes, high blood pressure, cardiovascular disease, and gastrointestinal problems (Bushnell et al. 2011, Ragland et al. 1987). This review explores the health research and other literature relevant to the health problems that may be caused or aggravated by restricted restroom access; health concerns that make restroom access more important or pressing, including commercial driverâs license issues such as hypertension and diabetes; and specific groups with increased restroom needs such as pregnant women and aging workers. Medical information and common experience suggest that restricted restroom access could contribute to adverse health and safety conditions and outcomes. However, research describing restricted restroom access in the workplace and how it might relate to these issues is limited. Additionally, comprehensive reviews of the impact on transit operators are unavailable. To fill in knowledge gaps, the research team performed a review of the literature describing how rest- room access could affect health and safety. The review covered peer-reviewed medical research, reports from industry, transit agency and expert technical sources, working and white papers, union-sponsored projects, and news articles. Figure B-1 summarizes the potential connections that are supported by the literature; neither the strength nor, in some cases, the direction of the associations has been established. What increases urination needs? â¢ Drinking â¢ Eating â¢ Pregnancy â¢ Age â¢ Illness â¢ Job stress â¢ Colder temperatures â¢ Whole body vibration What are the job stress & strain concerns? â¢ Harassment â¢ Anxiety â¢ Scheduling issues â¢ Vigilance â¢ Increased runtime â¢ Lost productivity â¢ Dignity â¢ Humiliation â¢ Distraction â¢ Long working hours What results are possible? â¢ Urological problems â¢ UTIs â¢ Kidney stones â¢ Gastrointestinal problems â¢ Constipation, impaction â¢ Cognitive impairment â¢ Reduced attention, awareness â¢ Motor vehicle accidents â¢ Cardiovascular disease â¢ Hypertension â¢ Atherosclerosis â¢ Heart attack â¢ Stroke â¢ Reproductive health â¢ Male fertility â¢ Low birth weight â¢ Cancer â¢ Bladder â¢ Colorectal â¢ Toxic shock syndrome â¢ Multiple organs affected Many likely mediated by dehydration Restricted restroom access can affect operator health â¢ Urological â¢ Central nervous system â¢ Gastrointestinal â¢ Cardiovascular â¢ Reproductive â¢ Multi-organ involvement What is the public health impact? â¢ Passenger safety â¢ Reduced hand washing â¢ Use of containers â¢ Voiding in vehicles or public areas Image developed by D. Wigmore Figure B-1. Connections to consider between restroom access and operator health and safety.
Summary of Health Literature 177 Health Factors Associated with Restroom Access for Transit Vehicle Operators The research team evaluated the evidence that restricted restroom access could adversely affect the health or safety of transit operators and the safety of the public. This review looks at its potential impact on biological systems and the pathophysiological mechanisms and pathways along which that impact could occur. It also considers possible mediators or moderators of any direct impact (Kraemer et al. 2001). The existing literature on the health effects of restricted rest- room access points at four main biological systems: urogenital, gastrointestinal, cardiovascular, and cognition via impacts on the central nervous system. Workplace exposures, individual con- tributors, complicating factors, intermediate outcomes, and health endpoints are highlighted in this review. Risk Factors, Explained Risk factors and outcomes interact in some complex ways (Kraemer et al. 2001). In the simplest case, a factor causes an outcome and is the only cause. Exposure to the factor occurs earlier than the outcome, which does not happen in the absence of the factor. The greater the exposure, the bigger the outcome. For example, an outcome might seem to be caused by exposure rather than the actual cause. If restricted restroom access is related to job stress and strain, and restricted restroom access contributes to adverse urological conditions, stress is considered a proxy for restricted access in causing urological outcomes. When two measures overlap or are strongly related to the same outcome, they both contribute to the outcome and affect each other. For example, both anxiety related to restricted restroom access and not taking prescribed diuretics could be strongly associated with cardiovascular con- ditions, such as high blood pressure. Anxiety about restroom access and deciding not to take the diuretic are related factors. Two risk factors can be independent of each other. For example, pregnancy and whole body vibration, which can both increase the frequency of urination, are made more of a problem by restricted restroom access. This could lead to urological conditions such as urinary tract infections. A mediating factor explains the impact of another variable on the outcome. In a restricted restroom access example, not using the restroom because of restricted access is the observed risk factor, dehydration from fluid restriction is the mediator, and a gastrointestinal problem, such as constipation, is the outcome. Finally, a moderator affects the relation between the other risk factor and outcome. An exam- ple would be the association between how the effects of dehydration and cognitive impairment of the central nervous system depend on age. Water as Mediator Many of the possible effects of restricted restroom access that are of concern to vehicle opera- tors might be the result of mild or more severe dehydration. Among professional drivers, dehy- dration may be caused by intentional restriction of fluid intake to reduce oneâs need to urinate. This restriction most likely occurs as a result of limited restroom access or use, such as when restroom time would conflict with on-time transit service (Mass et al. 2014). A potential con- tribution to the health problems observed in bus operators around the world is suggested by
178 Improving the Safety, Health, and Productivity of Transit Operators Through Adequate Restroom Access studies in which reduced fluid intake is associated with the release of a hormone that favors the development of hypertension, diabetes, and a variety of other low-fluid-intake disorders (Lang et al. 2017). Dehydration can occur when it is hot, especially in the context of physical activity and insuf- ficient replacement of water loss (Venugopal et al. 2016). In a double-blind laboratory study, healthy young women who were dehydrated via exercise or exercise plus a diuretic showed decreased sense of vigor and increased fatigue and anger on standardized assessments as com- pared with those who were not dehydrated (Armstrong et al. 2012); they also felt subjective increases in task difficulty, difficulty concentrating, and headache, as assessed by questionnaire. Most aspects of cognitive performance were not affected by dehydration. Men in a related study also demonstrated increased fatigue and tension/anxiety as well as changes in visual vigilance and working memory (Ganio et al. 2011). Does adequate hydration prevent urinary tract infections (UTIs)? A recent randomized con- trol study found that women with cystitis who increased their water intake above 1.5 liters per day had fewer episodes at 1 year than women who did not (Hooton et al. 2018). One review reported that adequate hydration reduces bacterial counts in the urine, thereby improving blad- der mucosal defenses (Beetz 2003). This report also revealed that the elimination of bacteria from the urinary tract is partially dependent on urine flow and that mild dehydration leads to decreased urine output and rates of flow, which tend to increase bacterial populations. Likewise, urination can flush the urinary tract of infecting organisms and reduce bacterial multiplication in the bladder (Denman and Burton 1992). However, even frequent voiding cannot completely eliminate organisms from the bladder, and bacteria may occasionally enter from the urethra, where they can multiply and invade the urinary tract, according to one comprehensive review (Beetz 2003). On the other hand, there is some evidence that concentrated urine may possess antibacterial activity. Additionally, the review revealed that highly concentrated urine may play a role in the reduction of bacterial multiplication after invading the bladder. The review con- cluded that there is insufficient evidence that an inadequate fluid intake leads to an increased susceptibility to UTIs (Beetz 2003). This ambiguity is supported by a review of literature though 2011 which identified 14 studies conducted to determine whether health conditions were related to dehydration or under- consumption of water (Armstrong 2012). Issues of concern included UTIs, chronic kidney disease and kidney stones, fatal coronary heart disease, venous thromboembolism, stroke, and cancer of the colon and bladder. Urolithiasis (kidney stones) was the only health outcome that was con- sistently associated with chronic low daily water intake. The review authors suggested methodo- logical improvements that could improve research on the otherwise plausible connection between fluid consumption and health. One report noted that the risk of kidney injury during fluid depletion is increased by medi- cations, including diuretics and nonsteroidal anti-inflammatory drugs (Feehally and Khosravi 2015), both commonly used by transit vehicle operators. While individuals with chronic kidney disease are less tolerant of extremes in fluid loading and deprivation, there is no consistent evidence that suggests that low fluid intake is linked with chronic kidney disease or progression of kidney disease. Areas of Potential Health Impact of Restricted Restroom Access Mood and Cognition Postponing urination following fluid consumption was associated with a decline in attention and working memory in a laboratory setting (Lewis et al. 2011). The effect of this postponement
Summary of Health Literature 179 was as strong as that observed for conditions associated with increased accident risk, such as fatigue and elevated blood alcohol levels. The report attributed this effect to the distraction caused by the urge to void, as well as increased pain if voiding was postponed for long enough. As discussed earlier, mood and, to some extent, cognitive impairment can occur because of dehydration (Armstrong et al. 2012, Ganio et al. 2011). Fluid loss can lead to internal physi- ological imbalances that impair central nervous system function (Wilson and Morley 2003). Suboptimal fluid intake likely leads to the release of a hormone regulating fluid balance that, in turn, appears to foster the development of several clinical disorders, including hypertension and cognitive impairment (Lang et al. 2017). The three areas of the brain most vulnerable to the effects of dehydration are the reticular activating system, the autonomic structures, and the cortical and midbrain structures. These three areas assist in attention and wakefulness, regulate psychomotor and physiological feed- back functions, and are responsible for thought, memory, and perception, respectively (Neelon and Champagne 1992). Delirium, another symptom of extreme dehydration, reflects the global impact of dehydration on cerebral function, although other CNS structures (noted above) are likely involved and activated on the basis of the hydration status of the individual (Neelon and Champagne 1992). For example, chronic subclinical dehydration is probably associated with anxiety and panic attacks, while fluctuating levels of tissue dehydration are possibly related to inattention and delusions (Wilson and Morley 2003). Additionally, experimental findings indi- cate a relation between cognitive dysfunction and the severity of dehydration. For instance, study participants have demonstrated progressive impairment in short-term memory and visual-motor function after exercising in warm conditions and experiencing moderate (2%) body fluid deficits (Gopinathan et al. 1988). A study of 26 volunteers designed to measure the impact of mild dehydration (1%â2% body water loss) found decreased vigilance and working memory along with increased tension/anxiety and fatigue associated with dehydration (Ganio et al. 2011). Furthermore, an exercise study found long- and short-term memory impairment, as well as impairment in visual-spatial function, perceptive discrimination, and reaction time following similar body fluid deficits (Cian et al. 2000). Increased fatigue following prolonged dehydration was also observed, corroborating clinical findings linking hydration status to oneâs quality of life (Cian et al. 2001). On the basis of the assumption that complex tasks require increased attention, the findings suggest that dehydra- tion competes for executive function, attention, and awareness, with similar processes occurring in other cognitive domains, which compromise overall cognitive performance (Cohen 1983). Some animal studies hint that age-related physiological changes in neural enzymes could exacer- bate the impact of dehydration on cognitive function (Wilson and Morley 2003). Cardiovascular SystemâHypertension, Cardiovascular Disease, Stroke Job stressors and excessive demands are related to work activities that require drivers to perform extra labor or engage in behavior that is or feels risky; carefully steering vehicles into oncoming traffic to avoid double-parked cars is one example (TÃ¼chsen et al. 2006a). Job stress- ors are associated with hypertension (HTN) and perceived distress after work (Rydstedt et al. 1998). Bus drivers are known to have excess cardiovascular disease, which is attributed in part to the physical stressors of the job, which include traffic congestion, safety hazards, noise, and ergo- nomic problems (Rydstedt et al. 1998). Furthermore, limited restroom access has been reported in the current research as leading to feelings of distress and sometimes to risky behaviors, such as speeding to get to a restroom on time. Transit bus operators have described experiencing significant stress related to lack of restroom access (R. Gillespie, unpublished data, 2012â2019). A report on bus drivers and job stress reveals how bus operators are concerned they are develop- ing blood clots in their legs, since they cannot leave their seats. The report also mentions how
180 Improving the Safety, Health, and Productivity of Transit Operators Through Adequate Restroom Access workers cannot go to the bathroom and are concerned about how this affects their kidney func- tion. One driver states there is âstress from one end to the otherâ (Whitford 2017). Occupational psychosocial stress, such as workplace harassment, is also related to atheroscle- rotic changes in the cardiovascular system (Lynch et al. 1997, Leka et al. 2010). Drivers carrying passengers were found to be at greater risk of circulatory diseases than drivers carrying goods, possibly because of their frequent interaction with passengers (Hannerz and TÃ¼chsen 2001). Shift work and working long hours, which are common among drivers, have been associ- ated with circulatory diseases such as cerebral vascular accidents (strokes) and also obesity, as reported among drivers in Sweden (TÃ¼chsen et al. 2006a, Emdad et al. 1998). Obesity is a risk factor for heart disease and HTN (Morris et al. 1956). In a rigorous epidemiologic study of white-collar workers, the authors noticed that these links were even more apparent when look- ing at those not usually at increased risk, such as younger age groups or nonsmokers (Shinton et al. 1991). Diuretic medications are commonly prescribed to control HTN. Taking such medications can be challenging for drivers if restroom access is limited. Not taking diuretics to control HTN may result in higher rates of uncontrolled HTN, leading to atherosclerotic changes in blood vessels and increased risk of stroke (TÃ¼chsen et al. 2006b). Gastrointestinal System Constipation Multiple health sources suggest that ignoring the urge to have a bowel movement can lead to constipation. Thus, limited access to restrooms could lead to constipation and related problems due to the intentional delays in bowel movements. Additionally, underhydration may play a role in constipation, as it affects gastrointestinal secretions, how water is absorbed, and stool consis- tency (Arnaud 2003). In results from the National Health and Nutrition Examination Survey, constipation was significantly associated with liquid intake from food and beverage sources lower than 1.8 liters per day (Markland et al. 2013). Fluid restriction and underhydration can reduce the water content of a stool and lead to constipation (Klauser et al. 1990). Furthermore, constipation can lead to impaction, which may include symptoms such as nausea, vomiting, abdominal pain and tenderness, anorexia, and distension (Arnaud 2003). An important local factor in constipation is reduced physical activity, as an upright posture promotes colonic motil- ity (Arnaud 2003). Colorectal Cancer Colorectal cancer is one of the most prevalent cancers in both men and women. One potential mechanism is related to low water intake, which contributes to the low fluid content of feces. This may lead to reduced fecal output and constipation. A recent epidemiological study linked chronic constipation to a higher incidence of colorectal tumors (Guerin et al. 2014). A study using data from the Canadian National Enhanced Cancer Surveillance System concluded that the risk of rectal cancer could be increased following sustained high diesel emission exposure, but the association was not strongly shown (Kachuri et al. 2016). However, decreased fluid con- sumption, which leads to reduced fecal output and prolonged transit time, could play a role by increasing the contact time of colorectal tissue with carcinogenic substances from diesel exhaust fumes. Increasing water intake may reduce the risk of colorectal cancer by decreasing bowel transit time and minimizing mucosal contact with carcinogens or by decreasing the concentra- tion of carcinogenic compounds in the water. An epidemiological study in Taiwan, a country with a relatively low risk of colon cancer, found that physical activity and increased water intake significantly reduced the risk of colon
Summary of Health Literature 181 cancer in men. However, the association between exercise and water intake on rates of colon cancer in women was not statistically significant in this study (Tang et al. 1999). Another study revealed how total fluid and water intake were inversely associated with colon cancer, especially tumors in men occurring in the distal segment (Slattery et al. 1999). A Seattle Cancer Registry study suggests that this association may be stronger in women (Shannon et al. 1996). Urinary tract Bladder Problems According to a panel of experts convened in 2010 to discuss the importance of a healthy blad- der on overall health, âWork environments need to provide adequate access, cleanliness and safety for toilet facilities; lack thereof can cause decreases in liquid intake or infrequent voiding by workers that can lead to compromised bladder function or urinary tract infectionâ (Lukacz et al. 2011). Working long hours without restroom access might also be associated with âinfre- quent voiderâs syndrome,â or restraining the desire to void for extended time periods, leading to the over-distension of the bladder muscle and damage to bladder sensation and muscular function. Drivers with diabetes may develop diabetic bladder dysfunction, which can lead to decreased bladder sensation with increased volume and mistiming of urinary urge; urge incon- tinence may also occur (Liu and Daneshgari 2014). A demanding work schedule, paired with restricted restroom access, is hypothesized as being related to infrequent voiding among drivers (Bendtsen et al. 1991, Mass et al. 2014). Urinary incontinence, especially in women, is a problem when paired with the lack of access to adequate restroom facilities. Urinary incontinence was reported by 42% of U.S. women in a large surveyâthe age distribution is discussed below (Melville et al. 2005). A recent Korean cross-sectional study exploring urinary incontinence in women by occupation found that the prevalence of urinary incontinence was âsignificantly associated with having an unclean and uncomfortable workplace, having a dangerous job and high probability of accidents, and feeling pressed for timeâ (Kim and Kwak 2017). Urinary Tract Infections Urinary tract infections (UTIs) are a frequently-voiced concern among female transit vehicle operators, who feel that their work contributes to symptoms and infections (R. Gillespie, unpublished data, 2012â2018). A Danish study found that women who voided three times or less per day had more UTIs than women who voided four or more times per day (Nielsen and Walter 1994). Female teachers who voluntarily restricted fluids by drinking less because they could not leave their classrooms had more than twice the risk of UTIs than women with adequate hydration (Nygaard and Linder 1997). This concern is supported by research in the clean room work environment where it may be difficult for workers to take water breaks or use the restroom because it is time consuming to don and doff clean room suits. Clean room workers studied in Taiwan had a higher prevalence of UTIs compared with other nearby workers and were significantly less likely to drink water frequently or use the restroom; voiding three or more times was associated with a lower risk of UTIs (Wang et al. 2002). Similar findings were observed among pregnant clean room workers in a more recent study by the same research team (Su et al. 2009). The risk of UTIs was higher among pregnant than nonpregnant clean room workers, a significant concern, as pregnancy is a well-documented risk factor for UTIs, and contracting a UTI during pregnancy can be asso- ciated with many obstetric and neonatal complications (Delzell and Lefevre 2000). Intensive health education can improve voiding behavior in clean room workers and reduce the preva- lence of UTIs (Su et al. 2006).
182 Improving the Safety, Health, and Productivity of Transit Operators Through Adequate Restroom Access Earlier research, focusing on case comparisons rather than workplace exposures, had mostly similar findings. One study found that infrequent voiding habits were seen in more than 60% of recurrent UTI cases; conversely, UTIs could be prevented by daytime voiding every 2 hours and one or two times at night (Lalli and Lapides 1969). In another study, patients with recurrent UTIs had a higher frequency of voluntary urinary retention for more than an hour after experiencing the urge to urinate than the control group (Adatto et al. 1979). These reports found no difference in the daily fluid intake between patients with recurrent UTIs and controls. One author hypothesized that the so-called âinfrequent voiding syndromeâ may result in muscular decompensation of the bladder, which leads to the development of a large bladder unable to contract, residual urine, and recurrent UTIs (Beetz 2003). In a study that compared the frequency of voiding in patients with recurrent UTIs and a group of healthy women, the patients had a greater frequency of voiding as compared with the control group (Seddon et al. 1980). It is possible that women with recurring UTIs had changed their behavior or sense of urgency because of ongoing irritation. However, as the frequency of voiding in both groups increased, the likelihood of UTIs also increased. Kidney Stones Among professional drivers, dehydration can be intentional, as they may restrict fluid intake in an effort to reduce the need to urinate. Dehydration is associated with high ambient tempera- tures, high amounts of physical activity, and the insufficient replacement of water loss (Siener and Hesse 2003). Lack of restroom access, lack of restroom use (when restroom breaks would have adverse financial impacts), or the pressure to provide on-time transit service may all inter- fere with driversâ hydration at work (Mass et al. 2014). A recent systematic review of occupation and stone formation suggested that âpractitioners must account for occupation when seeing a patient with new onset of stone formation. A detailed understanding of a patientâs access to water, access to bathroom facilities, exposure to ambient temperature, and liberties at work or school to attend to fluid and urination requirements are all mandatoryâ (Goldfarb 2016). Low fluid intake leads to low urine volume, which has been linked to urinary stone forma- tion. In a study that examined patients with diagnosed kidney, bladder, and urinary tract stones, low urine volume was the second most prevalent finding, with nearly 40% of patients classi- fied as âchronically dehydratedâ reporting low water intake (Embon et al. 1990). These authors and others suggested that, in some cases, kidney stones can be treated satisfactorily by increas- ing water intake and that increased fluid intake reduced the future risk of stone development (Curhan et al. 1993). In a clinical trial, authors studied the effect of high water intake, the role of urine volume, and calcium stone disease in patients and nondiseased individuals. They con- cluded that urine volume is a stone risk factor for calcium stone disease and that large daily intakes of water should be used for prevention of stone recurrences (Borghi et al. 1996, Siener and Hesse 2003). A review of studies examining the relation between water intake and kidney stone formation found that increased daily fluid intake could decrease the risk of formation and, especially, recurrence (Prasetyo et al. 2013), and an analysis of dietary factors indicated that decreased water consumption was related to kidney stone formation in Chinese men (Dai et al. 2013). In addition to professional drivers, health care professionals working in operating rooms showed a higher number of stone disease incidents; decreased access to water is related to the length of surgery or a busy operative schedule (Linder et al. 2013). Bladder Cancer Transit work may be a risk factor for bladder cancer, even after considering smoking, gender, and age. A 5% increased risk of bladder cancer was found in men in Copenhagen who performed bus, truck, and taxi labor (Jensen et al. 1987). In this same study, increased duration of employment was linked with increased risk. Another study found that long duration
Summary of Health Literature 183 of work in male motor vehicle drivers and males exposed to substantial traffic exhaust were at increased risk of cancer in the epithelial tissue lining of the urinary tract; the small number of women who were occupationally exposed made it difficult to assess their risk (Pesch et al. 2000). In a recent review studying the association between bladder cancer and occupation, bus driv- ers were second only to miners in elevated risk; motor mechanicsâ odds were similarly elevated (Reulen et al. 2008). Transit operators may limit their fluid intake because of restricted access to restrooms. How- ever, whether decreased fluid intake increases bladder cancer risk and how it might do so remains uncertain. Dehydration, a reduction in total body water, may be partially due to decreased fluid intake (Thomas et al. 2008). Diesel and nondiesel fumes and aromatic amines found in gasoline are examples of carcinogens that may become concentrated in urine and may exacerbate the association between dehydration and cancer (Silverman et al. 1983, Hoar and Hoover 1985, Mommsen and Aagard 1984, Clayson 1981). Dehydration may also exacerbate the association between bladder cancer and polycyclic aromatic hydrocarbons (PAHs), which are substances released from the combustion of gasoline and diesel fuel. The International Agency for Research on Cancer has recently determined there is sufficient evidence to link PAHs and bladder cancer in humans (Boada et al. 2015). Some possible mechanisms have been proposed to characterize how fluid intake may affect bladder cancer risk; the âurogenous contact hypothesisâ which considers the frequency of urination on urine concentration, is likely the most cited (Braver et al., 1987). This hypothesis states that higher fluid intake, accompanied by high volume and frequency of urination, reduces contact time with mutagens (i.e., exposures that often change cell DNA) and limits the effects of carcinogens on bladder tissue (Buendia Jimenez et al. 2015, Silverman et al. 2008). This hypoth- esis was supported in several studies. First, authors who examined the effect of water intake on bladder cancer found that high water intake and diluted urine decreased the time of contact between carcinogens in urine and led to a decreased number of mutations in cancer-related genes (Buendia Jimenez et al. 2015). Another study found that daily fluid intake was inversely related to the risk of bladder cancer (Michaud et al. 1999). Similarly, low fluid intake could also compromise cellular concentration of water, affect enzyme activity in metabolic regulation, and inhibit carcinogen removal (Altieri et al. 2003). Reproductive System Prostate Health Taxi drivers, like transit operators, have limited access to restrooms and may be at risk of related health problems. A study that compared symptoms of prostatism (obstruction at the neck of the bladder due to prostatic hypertrophy) among patients with prostate symptoms, taxi drivers, and barbers, revealed that patients and taxi drivers had similar prostate symptom scores, which were greater than the barbersâ scores. The rationale for the comparison groups was that barbers did not sit while they worked and had better access to restrooms. There was also a greater incidence of infrequent voiding in taxi drivers as compared with both other groups. A greater prevalence of prostatitis, prostate pain, and inflammation of the prostate not due to bacterial infection was also observed in taxi drivers as compared with barbers (Kim et al. 1998). The authors hypothesized that the more diverse voiding symptoms found in taxi drivers as compared with barbers may be due to working in constrained, prolonged, and seated environments. Another study found that prostate symptoms were more frequent and severe in a group of taxi drivers than in a group of office workers (Oh et al. 2004). The authors hypothesized that the taxi driversâ chronic abstinence from voiding and prolonged sedentary work environments
184 Improving the Safety, Health, and Productivity of Transit Operators Through Adequate Restroom Access might contribute to poor voiding functions and prostate-associated symptoms. Similarly, another report revealed that even young men exposed to prolonged sitting, infrequent voiding, and psycho social stress at work might be at greater risk of chronic prostatitis (Gao et al. 2007). A qualitative study evaluated concerns expressed by older men regarding their urological health (Pinnock et al. 1998). Voiding problems were discussed in terms of their impact on qual- ity of life rather than as health problems. Transit drivers pointed out that symptoms such as frequency and urgency were made worse by the lack of available toilets. One participant, a taxi driver, suggested that inflexible working conditions could increase the impact of mild urinary symptoms to the point where active treatment was sought. The driver would miss calls if he was not near a toilet because of fear of incontinence. The authors indicated that for a person with urgency or frequency, poor access to toilets can substantially increase the impact of symptoms or âbotherâ to the point where they affect the working capacity of the individual. Reducing symptom impact, e.g., by modification of the environment, would therefore seem to be an important goal for health promotion programs targeting preventable prostate disease morbidity, as well as those attempt- ing to reduce the cost of prostate disease for the community (Pinnock et al. 1998). Pregnancy and Birth Outcomes Concerns consistently voiced by female transit operators about the effects of restricted rest- rooms during pregnancy have not been evaluated systematically (R. Gillespie, unpublished data, 2012â2019). Concerns include womenâs felt need to use the restroom more frequently than men, menstrual issues, and pregnancy risks such as miscarriages and premature labor. Urinary fre- quency and urgency are commonly described by pregnant women (Connolly and Thorp 1999). Pregnant women also have up to four times the risk of developing UTIs. All these effects may be caused by anatomical or physiological changes of pregnancy. For example, during pregnancy, most womenâs urinary tract and bladder change, leading to increased bladder and urine volume and increased urinary stasis. The urine concentration also changes, with up to 70% of pregnant women experiencing bacterial growth in the urine. Furthermore, increases in urinary hormones may lead to a decreased ability of the lower urinary tract to resist invading bacteria (Delzell and Lefevre 2000). Speaking to the vehicle operatorâs biggest concern: UTIs are implicated in prema- ture labor, certain birth defects, and other adverse outcomes (Connolly and Thorp 1999, Delzell and Lefevre 2000, Howley et al. 2018, Ovalle and Levancini 2001). Some of these effects, such as preterm labor complications and low birth weight babies, are more likely even when bacteria growth in the urinary tract occurs without UTI symptoms (Romero et al. 1989). Additionally, characteristics such as race, ethnicity and comorbid conditions increase the risk of UTIs and, thus, adverse birth outcomes (Pastore et al. 1999a, 1999b). Male Infertility Certain occupational exposures (e.g., driving vehicles, sedentary employment, habitual sitting) are thought to contribute to chronic prostatitis due to intrapelvic venous congestion (Chiappino and Pisani 2002). If intrapelvic venous congestion becomes chronic, it can interfere with fertility (Chiappino and Pisani 2002). Likewise, other reports have suggested that impaired fertility might be associated with prolonged occupational sitting and related increases in scrotal temperature (Mass et al. 2014). Increase in scrotal temperature has been observed in men driving for prolonged periods (Bujan et al. 2000). It has been suggested that increased scrotal temperature affects sperm development, which may account for the longer time for men who are occupational car drivers to achieve conception (FigÃ -Talamanca et al. 1996). Kim and colleagues (1998) found a greater incidence of calcification and ejaculatory duct abnormality in taxi drivers as compared with patients with prostate symptoms and barbers. The authors hypothesized that seated environments, coupled with increased pelvic floor tension, might contribute to these findings.
Summary of Health Literature 185 In a large clinical study, the production of abnormal sperm (pathospermia) and lowered fer- tility were more common among occupational drivers than other patients being treated for male health issues. Pathospermia was correlated with the number of years driving, increasing after 4 years of work. Deterioration of sperm production was substantially greater in industrial hard machinery drivers than in automobile drivers (Sas and SzÃ¶llosi 1979). These studies referred to other research, indicating that industrial drivers have higher rates of prostatitis, urinary com- plaints, perineal pain, and the enlargement and congestion of the urological and reproductive systems (Sas and SzÃ¶llosi 1979, Pinevich and Smolâskii 1973). A study examining the association between potential risk factors for professional drivers (pro- longed sitting times, excessive heat, mechanical vibrations, stress, air pollution) and their repro- ductive health showed that taxi drivers had a lower prevalence of normal sperm than healthy men from the same clinic. After the researchers adjusted for age, smoking, and alcohol consumption, this association increased with years on the job. Other parameters, such as sperm motility, did not differ by group. The authors concluded that prolonged urban automobile driving might be a risk factor for sperm quality and morphology (FigÃ -Talamanca et al. 1996). A review of the impact of whole body vibration (WBV) on reproductive function showed inconsistent results. Sperm maturation and fetal growth and development may be affected by WBV. However, heat exposure and prolonged sitting, both factors that are likely increased when restroom access is hindered, increase the effect of WBV on these reproductive outcomes: âThe limited research and anecdotal evidence that does however exist should not be ignored and can be considered as the strongest indicator so far that adverse reproductive effect could be present and should be investigated further (Joubert 2010). Multiple Organ Systems: Toxic Shock Syndrome Toxic shock syndrome (TSS) is an acute-onset illness associated with fever, rash, and hypo- tension that can lead to systemwide organ failure (Wagner et al. 1984). Menstrual-associated TSS is found in otherwise healthy young women using high-absorbency tampons (McCormick et al. 2001, Davis et al. 1980). About 98% of women with menstrual-associated TSS reported tampon use, and 71% of cases for which tampon absorbency was reported used high-absorbency tampons. The Centers for Disease Control and Prevention reports that case fatality rates have decreased since the early 1980s. However, these data are likely underreported (McCormick et al. 2001). Factors that have led to decreased menstrual-associated TSS rates since the early 1980s include reductions in tampon absorbency; greater awareness of TSS, leading to more careful use of tampons; and standardized, improved labeling by the Food and Drug Adminis- tration (McCormick et al. 2001). Although TSS is extremely rare, the risk could be increased if limited restroom access discourages women from changing their tampons often enough. Public Health Impact as Described in the Press How many transit operators relieve themselves in public areas, use containers, or even soil the seat as they work is not known, according to transit agency managers and local union leaders surveyed for TCRP Research Report 216, but this issue does receive the most attention regarding restroom access in news and report sources. These events highlight the enormous stress experi- enced by transit operators who cannot reach a restroom in the time available or feel they cannot take the time to do so. The related public health impact affects not only operators but also transit vehicle cleaners, sanitation workers, and the public, who are all potentially exposed to human waste because of this.
186 Improving the Safety, Health, and Productivity of Transit Operators Through Adequate Restroom Access Many news articles refer to health concerns of transit workers, such as long bathroom wait- ing periods that may last up to 5 hours, pregnancy risks, menstruation, UTIs, employer rules that disallow food on the trains, gastrointestinal distress, and digestive diseases (Priestley 2015, Oxfam America 2016, Johnson 2017, Hedgpeth 2011, Stangler 2015). In some instances, limited access to restroom facilities has resulted in critical injuries and death (Ray and Tracy 2017, Wal- drop 2004). In 2004, Diane Boothe, a transit bus driver in the Portland, Oregon, area, was fatally run over by her bus as she rushed to a terminal restroom (Waldrop 2004). Eleven years later, Laquito Alvin of MiamiâDade County died while trying to stop her bus, which she had appar- ently left running because she had âjust a few minutes to go to the bathroom before starting the circuit all over againâ (DeFede 2015). Mechanical problems with the rear door had delayed her getting off, and the system designed to set off an alarm in this situation was not functioning. Recently, a New York City bus driver was hospitalized when trying to stop his bus from rolling into a Queens cemetery after leaving it to use a restroom (Ray and Tracy 2017). Publicizing these events can add additional stress for transit operators and lead employers to crack down on inappropriate behavior. Thousands of videos and images are posted to YouTube and Instagram showing bus drivers who have to relieve themselves at inconvenient times or inappropriate places or the signs of their doing so, such as containers filled with urine. Some of the coverage is empathetic to the plight of transit workers, but most of the posts function to shame the drivers. The presence of video footage or photographic evidence depicting transit operators peeing on the job not only perpetuates what a local union leader refers to as âan invasion of privacy,â but can also jeopardize transit employeesâ employment (Rodriguez 2016, Rosenbaum et al. 2015). For example, an article presenting a photo of many containers filled with urine on the side of an outside elevated subway track states âThe MTA âstrictly prohibitsâ littering of any kind, according to the agency rulebookâ (Rosenbaum and Harshbarger 2015). Health Issues and Changes That May Affect Restroom Access and Related Risk One of the most pressing questions for transit employers is what is the optimal time that people can go without urinating? Research has looked at the average number of times per day, rather than time. One typical estimate of six to seven voids a day is based on a 1988 study of 151 healthy Scandinavian women who kept 48-hour urination diaries (Larsson and Victor 1988). The average was 5.8, ranging from three to 11. Because more than 90% reported voiding fewer than 8 times a day, researchers continue to use this as a rule of thumb for defining overactive bladder (FitzGerald et al. 2002, Kowalik et al. 2019, Lukacz et al. 2009). A healthy person sleep- ing about 7 hours would then need to void about every 3 hours when awake. One of the few studies to assess patterns in a multiracial population found that the average frequency was every 3 to 4 hours, with 25% of women urinating more often than every 2 hours (Kowalik et al. 2019). That does not mean, however, that the intervals would be evenly spaced, as they are influenced by food and liquid intake. Although the common belief is that women urinate more often than men, this seems to be most true in their thirties, when womenâs frequency is highest and menâs is lowest (Burgio et al. 1991). Men and women get closer in frequency over time. This may be related to menâs increasing prostate issues and womenâs less-frequent UTIs. Waking to urinate may increase with age, especially in men, and could contribute to fatigue and decreased alertness during the work shift. In addition to the direct impact of restricted restroom access on the health of transit opera- tors, there are many health issues and individual concerns that affect how often operators will need to use a restroom and which what urgency. These include demographics such as age and
Summary of Health Literature 187 gender; chronic conditions including cardiovascular disease, diabetes, and irritable bowel syn- drome; and temporary conditions such as pregnancy, medication- or stress-related diarrhea, or even brief gastrointestinal illness that comes on during work. The need for bowel movements can change in a similar fashion with many of these conditions. For example, an aging workforce is likely to need more-frequent restroom access. In a large survey, incontinence was rated as moderate to severe by 20% of women in their 30s, increasing to 42% of women in their 60s. Incontinence became more severe as well as common over time. That cardiovascular disease and hypertension are common issues for transit operators has been recognized for decades (Winkleby et al. 1988, Ragland et al. 1987) and around the world. In surveys, focus groups, and informally, drivers report taking prescribed diuretics only when being tested for hypertension or only off-shift, so they will not be caught out on the road (J. Fisher, personal communication, 2018; R. Gillespie, unpublished data, 2012â2019). Both these decisions can cause problems, in the form of undercontrolled hypertension or excessive fatigue from waking to urinate more frequently. Diabetes can lead to increased voiding when uncontrolled, but as transit operators are required to establish adequate control in order to work, this should not be a consistent issue. However, over time, even controlled diabetes can lead to nerve damage that affects urinary urgency, both increasing bladder reactivity and limiting the bladder sensation of fullness (Panigrahy et al. 2017). Some diabetics will also want access to a clean and private location to test blood sugar at times that may not correspond to their scheduled breaks. Pregnancy, not a health problem in itself, frequently increases the urge to urinate and makes adequate hydration with frequent voiding even more important, as discussed earlier in this review. It makes the use of less-comfortable or -hygienic facilities even more distressing. Menstruating women may also require unscheduled restroom access with adequate space and supplies. Health Literature Summary The patterns of evidence from descriptive, observational, and experimental studies spanning 50 years suggest that restricted restroom access can negatively affect the physical and cognitive health of transit vehicle operators as well as their performance and productivity. This review has outlined some potential biological mechanisms and causal pathways between restricted rest- room access and adverse health effects; none of these have been studied in the context of transit operatorsâ work. The health model in Figure B-1 suggests potential links between restricted restroom access and health effects. The evidence is probably strongest for urinary tract infections, stress, and dis- tractions. Some of the more suggestive epidemiology pertains to taxi drivers. However, in most of that research, the impact of restricted restroom access or of hydration, a potential modifier, is not clearly separated from that of extended seated work. Additional concerns: Many studies are limited by methodological issues, including poten- tial confounding variables, small sample sizes, weaknesses in cross-sectional study design, and limited control matching. Some of the original literature is dated. At times, the research establishes statistical association but fails to provide a convincing rationale for the proposed mechanisms. Therefore, the health model can only suggest potential links between restricted restroom access and adverse health effects without establishing direct causeâeffect relation- ships or estimating the extent to which the health of transit vehicle operators might be affected.
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